Endoscopic-Guided Suture Lateralization for Bilateral Vocal Fold Paralysis: Surgical Tips for Better Outcome.

OBJECTIVE: This study aims to describe a precise description of suture lateralization (SL) technique and evaluate its effectiveness and safety in management of bilateral vocal fold paralysis (BVFP). METHOD: A preclinical cadaveric study followed by application on a case series of BVFP patients. After the preliminary study executed to precisely localize the optimal sites for needle insertion, a prospective interventional study was conducted on 19 subjects presenting with respiratory distress due to BVFP. Data collection included their clinical presentation and a detailed assessment including auditory perceptual assessment, laryngoscopy (rigid or flexible), and video fluoroscopic swallowing study. RESULTS: Widening of the inter-glottic distance at the site of the sutures was statistically significant (P < 0.001). Decannulation was achieved in three out of four tracheotomized patients. The suturing led to a significant difference in loudness, jitter, and harmonic-to-noise ratio (P = 0.042, 0.004, and ≤0.001, respectively). CONCLUSION: This study suggests that SL is a feasible and effective technique with low incidence of adverse events and the potential of reversibility. Optimal localization of the suture insertion points translated into less intraoperative manipulation of the cords and shorter operative time.

Medial Flap Coblation Turbinoplasty Versus Submucous Resection: Outcomes.

BACKGROUND: Variable surgical options are available for turbinate reduction. These options include total turbinectomy, partial turbinectomy, submucosal resection, laser surgery, cryosurgery, electrocautery, radiofrequency ablation, and turbinate out-fracture. However, there remains a lack of consensus for the preferred technique. OBJECTIVES: The aim of this study was to describe the use of coblation for medial flap turbinoplasty procedure. Furthermore, the outcomes of this technique were compared to submucous resection in terms of improvement of patients' symptoms, postoperative bleeding, crusting, and pain scores. METHODS: This prospective, randomized, comparative surgical trial was conducted on 90 patients. Patients were randomly allocated into 2 groups: medial flap coblation turbinoplasty group (n = 45), and submucous resection group (n = 45). The outcomes of both techniques were analyzed and compared. RESULTS: Both techniques were equally in alleviating patients' symptoms of nasal obstruction. However, postoperative healing was significantly better in medial flap coblation turbinoplasty group. Additionally medial flap turbinoplasty showed a statistically significant better outcome in terms of postoperative bleeding, crusting and pain scores. CONCLUSION: Both submucous resection and medial flap coblation turbinoplasty are effective in relieving nasal obstruction and enabling optimal volume reduction with preservation of function of the inferior turbinate. Coblation turbinoplasty has superior outcomes in terms of better healing and less postoperative pain and crusting.

Nasal Spine of the Frontal Bone: A Consistent Landmark for Safe Outside-In Frontal Drill-Out.

BACKGROUND: Outside-in frontal drill out entails drilling the frontal sinus floor in the midline before identifying and dissecting the frontal recesses. It is a more direct approach, especially in revision surgery or cases with challenging anatomy. OBJECTIVES: The aim of this study was to highlight the anatomical and surgical concepts for easy and safe outside-in frontal drill out by a preclinical anatomic study on cadaveric heads. In addition, to review our experience with this approach over a 5-year period for challenging frontal sinus pathologies. METHODS: The study included 2 sectors; a preclinical study, in which 5 cadaveric heads were dissected and studied to identify and standardize the anatomical landmarks of this approach. This was followed by a clinical case series which included 22 patients with challenging frontal sinus pathologies that were treated with this proposed approach. RESULTS: We concluded from the anatomic study that the nasal spine of the frontal bone (NSFB) and its anatomical orientation in relation to the nasal branch of the anterior ethmoidal artery (NBAEA) is a consistent landmark that enables the surgeon to identify the correct coronal trajectory of drilling to avoid injury of the cribriform and the skull base. The clinical case series included 22 patients that were successfully treated with the proposed approach. No intraoperative nor postoperative complications were reported in this study. Long-term follow-up showed that the frontal neo-ostium was patent in all cases (n = 22). CONCLUSION: Outside-in frontal drill-out is a safe and easy approach; especially in challenging frontal sinus pathologies; using the NSFB and its anatomical coronal orientation to the NBAEA as a consistent landmark, anterior to the skull base. This approach offers early, safe, and direct bone removal without the need for initial identification and dissection of the frontal recess.

Outcome comparison of submucous resection versus combined submucous diathermy and outfracture for treatment of inferior turbinate hypertrophy.

OBJECTIVES: The aim of this study was to compare the outcome of submucous resection and combined submucous diathermy with outfracture technique in treatment of nasal obstruction caused by inferior turbinate hypertrophy. METHODS: This study is a prospective randomized clinical trial involving 90 patients with hypertrophied inferior turbinate not responding to medical treatment. All patients were selected with equal or near equal mucosal and bony turbinate components using computed tomography (CT) and then randomly allocated into two groups; group A (n = 45): underwent submucous resection in both sides and group B (n = 45): underwent combined submucous diathermy and outfracture in both sides. Subjective (NOSE score) and objective (4-grades endoscopic classification system and PNIF evaluation) measures of nasal airflow were done preoperatively and postoperatively. RESULTS: Subjective assessment using NOSE scale proved that both techniques were effective in relieving nasal obstruction as it improved in both groups postoperatively compared to the preoperative data. However, resection technique was better than diathermy technique with a statistically significant difference (p < 0.05), while objective assessment of nasal obstruction showed better results in resection group than diathermy group, but with no statistically significant difference. CONCLUSION: Both techniques are effective in relief of nasal obstruction due to inferior turbinate hypertrophy. However, submucous resection showed marked improvement compared to diathermy technique especially at long-term follow-up.

Nasopharyngeal Angiofibroma Staging with a Novel Nominal Basis: An 18-Year Study in a Tertiary Center.

OBJECTIVE: To develop a systematic method for anatomic mapping of juvenile nasopharyngeal angiofibroma (JNA) tumors to standardize communication, facilitate surgical planning, and convey prognosis. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Following Institutional Review Board approval, we performed a retrospective review of radiologic and angiographic data of patients with JNA presenting to the Department of Otolaryngology-Head and Neck Surgery, Mansoura University, from 2001 to 2017. All patients underwent angiography with embolization and had >1-year follow-up. Based on frequently involved anatomic sites and factors predictive of prognosis, the NSF-COR staging system (nose/nasopharynx, sinus, fossa-cranium, orbit, residual internal carotid artery supply) was developed to explicitly convey anatomic site of involvement and presence of residual vascularity. We validated the NSF-COR staging system against other systems with Pearson chi-square test based on risk factors and clinical outcomes of blood transfusion volume, recurrence, and JNA resectability. RESULTS: Fifty-four patients met inclusion criteria, where all primary cases (100%) demonstrated nose/nasopharynx involvement, followed by sinus (85.2%), natural fossae (85.2%), intracranial (26%), and orbital involvement (16.7%). These sites, with assessment of residual internal carotid artery vascular supply, were used to develop the NSF-COR anatomically based staging system. The components COR showed significant association with clinical outcomes of blood transfusion and recurrence. Contingency coefficients between the NSF-COR staging system and available staging systems showed significant correlations (P < .05) for prognosis. CONCLUSION: The NSF-COR staging system conveys a communicable anatomic map of JNA tumors that integrates residual vascularity of the tumor and demonstrates strong concordance with current staging systems to assess clinical outcomes.

Association of Periosteal Sweeping vs Periosteal Preservation With Early Periorbital Sequelae Among Patients Undergoing External Perforating Osteotomy During Rhinoplasty.

IMPORTANCE: Periorbital sequelae are a significant source of early postoperative morbidity after rhinoplasty, particularly after an osteotomy is performed. OBJECTIVE: To compare postoperative periorbital sequelae after external perforating lateral osteotomy in rhinoplasty using a periosteal sweeping vs a periosteal preserving approach. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study conducted at a tertiary referral center located in Mansoura, Egypt, included 28 patients who underwent external perforating lateral osteotomy in open rhinoplasty between January and May 2017. EXPOSURES: Periosteal sweeping was performed on one side of the nose and periosteal preservation was performed on the other side during external perforating lateral osteotomy. MAIN OUTCOMES AND MEASURES: Periorbital sequelae, including eyelid edema, periorbital ecchymosis, and subconjunctival hemorrhage, were assessed on both sides of the face on postoperative days 1, 7, and 21 by 2 independent surgeons using the scale first proposed by Kara and Gökalan in 1999. The scales for eyelid edema ranged from 0 to 4, for ecchymosis from 0 to 4, and for subconjunctival hemorrhage from 0 to 2, with higher values indicating greater edema, ecchymosis, and hemorrhage, respectively. Differences in the 3 time points and differences between the 2 osteotomy methods were analyzed. RESULTS: In total, 19 men and 9 women with a mean (SD) age of 23.7 (3.9) years were enrolled. All patients showed significant decreases in eyelid edema on postoperative days 7 and 21 compared with day 1 (1.71 and 1.39 vs 2.89 for the swept side, and 1.86 and 1.46 vs 2.68 for the preserved side; both P < .05) and in periorbital ecchymosis (2.02 and 1.13 vs 2.86 for swept side, and 2.05 and 1.13 vs 2.82 for the preserved side; both P < .05). A significant decrease in subconjunctival hemorrhage was observed on day 21 compared with days 1 and 7 (1.79 vs 2.11 and 2.11 for the swept side, and 1.71 vs 2.14 and 2.14 for the preserved side; both P < .05). The mean rank score for eyelid edema on day 1 for the swept side was significantly higher than that for the preserved side (33.18 vs 23.82, P = .02), and the mean rank score for periorbital ecchymosis on the swept side was significantly higher than that for the preserved side (33.59 vs 23.41, P = .01). Although both eyelid edema and periorbital ecchymosis appeared to remain greater on the swept side on postoperative days 7 and 21, the differences no longer reached statistical significance. Periosteal preservation was not associated with minimizing subconjunctival hemorrhage postoperatively. CONCLUSIONS AND RELEVANCE: This study suggests that lateral nasal osteotomy is associated with varying degrees of eyelid edema, periorbital ecchymosis, and subconjunctival hemorrhage. Compared with sweeping the periosteum, preserving the periosteum in an external perforating lateral osteotomy was associated with less eyelid edema and periorbital ecchymosis in the early postoperative period. LEVEL OF EVIDENCE: 2.

Surgical correction of bifid nose.

OBJECTIVES: Evaluation of the aesthetic outcome and functional aspect after surgical correction of bifid nose by combined Millard forked flap with external rhinoplasty BACKGROUND: Bifid nose is a rare congenital anomaly that results during facial development but the explicit mechanism is not clearly understood. Clinical findings are quite variable with a wide range of severity. Surgical correction still represents great challenge to facial plastic surgeons; extensive deformities in many cases, rarity of condition and paucity of publications are contributing factors. METHODS: Surgical correction of six patients with bifid nose by a combined Millard forked flap with external rhinoplasty RESULTS: The aesthetic and functional outcomes were acceptable for all patients and parents. There were no considerable postoperative complications. CONCLUSIONS: This approach is highly effective for various grades of bifid nose. Early management is preferable to avoid psychological morbidity. Secondary rhinoplasty is usually needed for cosmetic refinement.

Midline nasofrontal dermoids in children: A review of 29 cases managed at Mansoura University Hospitals.

OBJECTIVES: Nasal dermoids are congenital anomalies constituting 3.7-12.6% of dermoids in the head and neck. Most of lesions are superficial but there is always a risk that it may end blindly within the deep structures of the nose or extend intracranially. Complete excision, regardless of extension, is essential and must be balanced against cosmoses. This study reviews the clinical characteristics and imaging findings as well as the appropriate surgical approach adopted for 29 cases managed at Mansoura University Hospitals. METHODS: A retrospective analysis was performed in 29 patients admitted for management of nasal dermoid between Jan 2001 and Jan 2015 at the Otolaryngology department of our tertiary referral university hospital. Recorded data included patient's demographics, complaint, lesion's site, pre-operative radiological findings, surgical technique, intra-operative findings, and post-operative squeal. RESULTS: This series included 12 (41%) female and 17 (59%) male children, with a mean age of 2.5 years. Twenty seven children presented with a nasofrontal swelling of which 20 had an apparent sinus. Other presentations included a swelling in the inner canthum (1), nasal tip and columella (1). Nine (31%) patients had a history of infection and two patients gave a positive history of meningitis. Intracranial extradural extension was identified in 10 patients (34.5%) during preoperative imaging. Surgical modalities included local excision and direct closure (12), open rhinoplasty (7), bicoronal excision and craniotomy (10). In 9 cases, the tract was adherent to the dura but was carefully dissected and in one case resection required excision of a segment of dura and reconstruction. In a follow up period of 1-8 years, recurrence was detected in one case and the cosmetic results were satisfactory. CONCLUSIONS: Those lesions are rare and require early precise surgical planning to achieve complete en bloc excision. This study reports a low morbidity associated with management of nasal dermoids with intracranial extension.